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Tag No.: A0117
Based on review of policies and procedures, medical record, observation, and staff interviews it was determined the hospital failed to provide a copy of Patient Rights to one of one patient. ( patient # 4)
Findings include:
The hospital policy "Patient Rights and Responsibilities" dated 10/13 revealed: "...the healthcare worker who gathers data upon admission will provide the patient or patient"s representative the "YRMC Patient Information Guide" that contains the patient Bill of Rights information and ask the patient or patient representative to sign the appropriate place indicating the patient or their representative has received this information...Outpatients will be given a copy of the patient Bill of Rights...Patient Bill of Rights documents are posted in the following areas: Emergency Department...."
Review of the medical record for patient # 4 identified a form titled "Conditions of Admission" (COA), dated 09/12/2014 at 10:11 am. The form revealed that Patient Rights are not included on the form. None of the COA forms contained information about patient rights.
The Director of Quality (employee # 26) confirmed in an interview conducted on 01/29/2015 that the COA form does not contain Patient Rights.
Observation on tour in the Emergency Department on 1/29/2015 at 3:30 pm revealed Patient Rights were not posted in the area and no handouts were available.
Employee # 59 confirmed in an interview conducted on 01/29/2015 at 4:00 pm that the Patient Rights are to be given to a patient upon registration of the patient into the Emergency Department(ED). Employee # 59 also confirmed in this same interview that if a patient has been seen in the ED previously then they do not offer the patient Rights form to the patient. Also, she confirmed that there were not Patient Right handouts available for distribution.
Employee # 8 (Compliance Officer) confirmed in interview on 1/29/2015 at 4:10 pm that the Patient Rights were not posted in the Emergency Department area, also, employee # 8 confrmed there were no Patient Rights handouts available.